Advance Care Planning for the Homeless: A Community Collaboration
UCLA Medical Center, Santa Monica is an academic medical center that serves a large homeless patient population, many of whom have chronic and potentially life–limiting illnesses. Our emergency room sees approximately 50 homeless patients during an average 30–day period. Given the transitory patterns of this population as well as the complex needs, their healthcare goals and instructions are typically overlooked and or unknown. By educating and engaging the homeless population in Advance Care Planning (ACP) we hope to aide in addressing the issues this complex population faces.
ACP conversations include exploring goals of care with the hope of completing an Advance Healthcare Directive (AHCD) for that patient. This allows the patient to have his/her healthcare wishes documented and respected by healthcare institutions. Without an AHCD, the patient is treated aggressively, which is the default when healthcare instructions are unknown. Research has found about 70% of Californian’s would prefer to have a “peaceful death” at home. However, due to lack of advance care planning, over 60% die while being treated at healthcare facilities and 20% will spend more than 7 days in the ICU in their last 6 months of life. Homeless individuals surveyed expressed the same desires and goals for their end–of–life care to result in a ‘peaceful death.’ The Palliative Care Clinical Nurse Specialist (CNS), Chaplain and Social Worker at UCLA–Santa Monica Hospital observed the need for providing these ACP conversations with the homeless patients, as the conversations were rarely had.
In collaboration with a physician champion and the Spiritual Care Department, the Palliative Care Team obtained a grant from the Coalition for Compassionate Care of California (CCCC) in order to create an outreach plan with the goal of completing AHCDs within the homeless community. Initially, we collaborated with our own administration and trained hospital in–house staff on ACP. The stress of being in the hospital and being hospitalized for a short period did not allow for ACP conversation, much less AHCD completion. Therefore, we decided to explore other opportunities and collaboration for education and training with the local community agencies that worked with the homeless population.
Collaborating with community agencies has proved to be successful and instrumental in shaping our outreach efforts. We sought out collaboration with agencies that worked with our homeless community. We reached out and collaborated with The People Concern, St. Joseph’s Center and Venice [End Page E14] Family Clinic (VFC). The details of our program was shared with the agencies, which was followed by educational trainings that were hosted at our hospital as well as at their respective agencies.
We were effective in educating the agencies in ACP, something they had not considered a priority with the homeless population. The trainings were just as educational for us as the agencies were able to teach us about the system our homeless patients navigate through. Continuity is a significant part in collaborating with the local agencies. We believe the patient that is receptive to ACP will follow–up with his/her community case manager, therefore educating case managers became a cornerstone of our outreach effort.
In addition to community educational training, we have offered direct ACP education and information to homeless clients within our community. We have been successful at a local food bank, where we have been able to engage homeless individuals in ACP education, as well as offering community resources on a monthly basis. We continue to explore other collaborations, most recently with other nursing and student organizations. For example, the Clinical Nurse Specialist (PCCNS) has provided trainings for the American Association of Critical–Care Nurses (AACN), which has resulted in additional volunteers. These connections have provided individuals interested in our training, and ultimately new volunteers have engaged in direct outreach at the foodbank. We realized providing ACP information in a familiar setting increases the likelihood of a meaningful conversation as well as a completed AHCD.
One of the biggest challenges has been finding an effective way to share our ACP conversations and completed AHCDs with community organizations. A central database where ACP conversations and AHCDs can be stored and accessed with inter-agency access does not exist. We have collaborated with community agencies and organizations to explore the use of existing as well as establishing a database that will allow for access to ACP information. In the meantime, we obtain written consent from the patients to share ACP conversations and completed AHCDs with the community agencies mentioned earlier in this article. The community agency will then upload the AHCD into their system known as Homeless Management Information System (HMIS). The advantage to HMIS is that information can be stored there. The disadvantage to HMIS is it is not interagency accessible. A few have accessed it amongst the community agency staff. Therefore, it has been imperative to establish and maintain relationships with the community agencies to ensure information is shared and accessible.
The work is substantial with both barriers and rewards. To date we have trained over 100 staff and community members on ACP, provided over 150 ACP educational materials to homeless individuals and held over 100 ACP conversations. These efforts have resulted in eight completed AHCDs. Our goal of engaging in ACP outreach is fulfilled and ongoing. We hope to continue our work through continued education and reaching out for new volunteers. [End Page E15]